Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
Medicare Eligibility for People With Disabilities
Even if you’re under the age of 65, you can qualify for Medicare if you have certain disabilities. You may be eligible for Medicare coverage if any of the following apply to you:
- You have ALS: If you have amyotrophic lateral sclerosis, often referred to as Lou Gehrig’s disease, you may qualify for Medicare if you receive Social Security Disability Insurance (SSDI) benefits.
- You have ESRD: If you have end-stage renal disease, you may qualify for Medicare if you receive regular dialysis or your doctor determines that you need a kidney transplant.
- You’re receiving SSDI: To qualify for SSDI benefits, you must have enough work credits from contributing to Social Security. You must also meet the definition of a disability under the Social Security guidelines. The Social Security Administration (SSA) considers you disabled if you can’t do the work you used to do because of your medical condition, you can’t perform other work due to your medical condition, and your disability is expected to last for at least 12 months or result in your death.
- You’re receiving disability benefits from the RRB: If you’re under the age of 65, you may qualify for Medicare if you’ve been receiving monthly RRB disability benefits based on a total disability for at least 24 months. You must also meet the definition of a disability under the Social Security guidelines.
|Eligibility type||How to qualify for Medicare||When you qualify for Medicare|
|ALS (Lou Gehrig’s disease)||You may qualify for Medicare if you’re diagnosed with ALS (Lou Gehrig’s disease).||You should be automatically enrolled in Medicare if you receive SSDI benefits due to your ALS diagnosis.|
|End-Stage Renal Disease (ESRD)||To qualify for Medicare with ESRD, you must need regular dialysis or require a kidney transplant.||Medicare has a waiting period for people with ESRD on dialysis. Coverage typically doesn’t begin until the fourth month of your dialysis treatments. If you need a kidney transplant, you qualify for Medicare coverage the month you’re admitted to a Medicare-approved facility for the transplant. If your transplant is delayed, then your Medicare coverage can begin two months before the scheduled transplant date.|
|Social Security Disability Benefits (SSDI)||To qualify for Medicare coverage, you must have enough work credits to qualify for SSDI. You must also have a disability expected to last for more than one year.||Once you’ve been approved for SSDI benefits, you qualify for Medicare after a 24-month waiting period.|
|U.S. Railroad Retirement Board (RRB)||To qualify for Medicare coverage as part of your RRB benefits, you must have a disability as defined by the Social Security Administration.||You may qualify for Medicare if you’ve been receiving monthly disability benefits based on a total disability for at least 24 months.|
Can you work while receiving Medicare under a disability?
In some cases, it’s possible to work while receiving Medicare and SSDI or RRB disability benefits. Social Security offers work incentives and operates the Ticket to Work program to give individuals with disabilities the opportunity to earn some income without losing their benefits. During a trial work period, you’re allowed to collect your full Social Security benefits no matter how much you earn, as long as you report the work and continue to have a qualifying disability.
Once the trial period is over, you have 36 months to work without losing your SSDI benefits, provided you don’t have “substantial” earnings. As of 2021, a monthly income of $1,310 counts as substantial earnings to determine your continued eligibility. This amount increases to $2,190 per month if you’re blind. You may be able to earn more if you have certain expenses that help you work, such as specialized equipment or a personal attendant. Even if your substantial earnings prompt Social Security to stop your SSDI benefits, you’ll still have free Medicare Part A for at least 93 months after you finish the trial work period. After 93 months, you’ll need to pay a monthly premium if you want to keep your Medicare Part A coverage.
If you receive disability benefits from the Railroad Retirement Board, you won’t receive your annuity benefit for any month in which you earn more than $1,020 in income after deducting relevant work expenses. The RRB may also find that you’re engaging in substantial gainful activity, or productive physical and/or mental duties. If the RRB determines that you’re engaging in substantial gainful activity, your RRB disability benefits and your Medicare coverage may be terminated.
Enrolling in Medicare With a Disability
In some cases, you’ll be automatically enrolled in Medicare Parts A and B, also known as Original Medicare, if you have a disability. Enrollment in Medicare Part C, a Medicare Advantage plan as an alternative to Original Medicare, and Medicare Part D (drug coverage) isn’t automatic, however, so you need to decide if you want either type of coverage. Medicare Part C and Medicare Part D have annual enrollment periods, which means you have a limited amount of time each year to sign up or make changes to your existing plan. You may also want to delay your enrollment in Medicare Part B depending on your circumstances.
Automatic Medicare Part A and Part B enrollment
Under some circumstances, you may be automatically enrolled in Medicare Parts A and B:
- You’ve been receiving SSDI benefits for 24 months.
- You’ve been receiving RRB disability benefits for 24 months and don’t have a disability freeze.
- You have ALS and you’ve received one SSDI payment or one RRB disability payment.
Some people choose to delay Medicare Part B enrollment because they have some other type of health coverage. If you have ESRD and take Medicare Part A while delaying your Medicare Part B enrollment, you’ll lose the right to sign up at any time during the 30-month ESRD coordination period. As a result, you may end up with a costly gap in coverage.
When to enroll in Medicare
Medicare Part C, also known as Medicare Advantage, is a type of Medicare health plan administered by a private insurer instead of the federal government. Medicare Advantage Plans combine Part A and Part B coverage, and frequently offer drug coverage as well. Medicare Advantage Plans may also cover dental care, vision care, and other services not covered by Original Medicare. Medicare Part D is a drug coverage plan that helps pay for prescription medications. You can enroll in Part D if you’re enrolled in Original Medicare, or if you are enrolled in a Medicare Advantage plan that doesn’t include prescription drug coverage. You must be enrolled in Medicare Parts A and B to join a Medicare Advantage (Part C) or Part D plan.
Enrollment in Medicare Part C and Medicare Part D isn’t automatic. If you’re under age 65, have a disability, and are newly eligible for Medicare coverage, you can sign up during the seven-month period that starts three months before your 25th month of receiving SSDI or RRB disability benefits and ends three months after your 25th month of receiving these benefits. This is known as your initial enrollment period.
Once you’re enrolled in a Medicare Advantage plan, you can switch from one plan to another or switch back to Original Medicare during the Medicare Advantage annual open enrollment, which runs from January 1st to March 31st each year.
- Change from Original Medicare to a Medicare Advantage (MA) plan
- Change from a MA plan back to Original Medicare
- Switch from one MA plan to another, with or without drug coverage
- Sign up for a Medicare Part D plan, switch Part D plans, or drop your Medicare Part D coverage.
You can prepare for open enrollment by comparing Part C and Part D plans to determine which ones are likely to leave you with the lowest out-of-pocket costs. Whether you have Original Medicare with a drug plan or have a MA plan with drug coverage, you are still responsible for the Part B monthly premium.
Medicare enrollment options
If you’re not automatically enrolled, there are several ways to initiate the enrollment process:
- Online: Use the Medicare Plan Finder to compare plans based on covered services and out-of-pocket costs. Select Medicare Advantage Plan if you want to enroll in Medicare Part C. If you want to sign up for a Medicare Part D plan, choose Original Medicare. The Medicare Plan Finder displays important information about each plan, such as the monthly premium, the annual deductible, and the copays for primary and specialty care. It also explains what’s included with each plan. For example, some plans cover hearing, vision, and dental services. When you’re ready to apply for Medicare online, visit the Social Security Administration
- Phone: To enroll by telephone, call the Social Security Administration at 800-772-1213. If you use a TTY service, call 800-325-0778.
- In person: If you prefer to apply in person, visit your local Social Security office. Use the Office Locator to determine which SSA office serves your area. You don’t need to make an appointment to discuss Medicare enrollment with a Social Security employee.
How Much Does Medicare Cost?
Your out-of-pocket costs will depend on which Medicare coverage you have. Medicare Part A typically costs nothing, but you may have to pay an annual premium if you didn’t work and pay Medicare taxes for enough quarters. Medicare Part B, Part C, and Part D all have separate premiums and deductibles.
Part A covers inpatient care in a hospital, hospice, or skilled nursing facility. It also covers home health care. If you paid Medicare taxes for fewer than 30 quarters, you’ll pay up to $471 per month for your Part A coverage. If you paid Medicare taxes for 30 to 39 quarters, your Part A premium will be up to $259 per month. You’ll also have to pay a deductible for each benefit period. For 2021, the deductible is $1,484. Each benefit period starts when you enter a hospital or skilled nursing facility and ends when you haven’t received inpatient care for 60 consecutive days. This means you may pay a deductible more than once in a calendar year depending on how often you need inpatient care.
For Part B coverage, you’ll pay a premium, a deductible, and coinsurance. For 2021, the standard Part B monthly premium is $148.50. You may have to pay more if you have a high income, but you won’t need to pay more than the standard premium unless your modified adjusted gross income from two years ago exceeds a certain amount; for 2021, this amount is $88,000 in individual income and $176,000 in joint income if you’re married. The deductible, or the amount you must pay before Medicare starts to cover your medical expenses, is $203. Once you meet your deductible, you’ll pay 20% of the Medicare-approved amount for most services.
Because Medicare Advantage Plans are offered by private insurance companies, there’s no standard premium for Part C coverage. However, most plans still require that you pay a portion of or all of the Part B monthly premium. When you use the Medicare Plan Finder, you can compare plans based on how much they cost and what services are included. If you have a disability, you may want to pay a little more in premiums for a plan with lower out-of-pocket costs. You’ll pay more for your coverage each month, but you won’t have to pay as much when you need medical care.
Medicare Part D plans are also offered by private insurance companies, which means the premiums vary based on the provider and the plan you select. The Medicare Plan Finder allows you to enter the names of the medications you take to determine how much you might pay for prescriptions with each plan. Depending on what the plan covers and the amount of the deductible, your premiums can range from a few dollars per month to more than $100 per month. The more expensive plans typically have no deductible or a small deductible, while inexpensive plans have higher deductibles or may not cover as many drugs.
Qualified Medicare Beneficiary Program
If you have trouble paying your out-of-pocket Medicare costs, you may qualify for the QMB program. To be eligible, you must meet certain income and resource limits. For 2021, the monthly income limit is $1,094 for individuals and $1,492 for married couples, while the resource limit is $7,970 for individuals and $11,960 for married couples. Resources include bonds, mutual funds, stocks, and money in checking or savings accounts. The QMB program helps pay Medicare Part A and Medicare Part B premiums, and it may also help with coinsurance, deductibles, and copays under certain circumstances.
Extra Help Program
The Extra Help program helps cover the cost of a Medicare prescription drug plan. You may qualify for the program if you live in the United States, are enrolled in Medicare, and have limited income and resources. To receive help via this program, your assets, including investments and real estate, must not be worth more than $14,790 if you’re not married or not living with your spouse or $29,520 if you’re married and living with your spouse. Unlike some resource-based programs, Extra Help doesn’t count your life insurance, the value of your home, or the value of any vehicles, burial plots, or personal possessions toward the resource limit.
Medicare Resources for People With Disabilities
If you need help determining if you’re eligible for Medicare, navigating the Medicare enrollment process, or understanding how Medicare coverage works with SSDI or RRB disability benefits, consult the resources below.
- State Health Insurance Assistance Programs: SHIPs offer to counsel individuals who are eligible for Medicare due to their age or disability status. When you schedule an appointment with a SHIP counselor, you’ll gain access to state-specific resources that can help you compare plans and determine which one gives you the best coverage at the most manageable cost.
- Medicare: The Medicare website provides information about each type of Medicare coverage, along with plan comparison tools and other resources to help you make informed decisions about enrolling in Medicare. The site also has resources specifically for individuals with a disability, such as fact sheets on enrolling with ALS or ESRD.
- Center for Medicare Advocacy: The Center for Medicare Advocacy aims to ensure that eligible individuals have equal access to health care and comprehensive Medicare coverage. The CMA focuses much of its efforts on helping those with disabilities and chronic health conditions, making it an excellent resource for anyone with a disability.
- Medicare Rights Center: The Medicare Rights Center is an independent organization offering counseling, education, and advocacy services to ensure that Medicare-eligible individuals and their families can make informed decisions about health coverage. MRC also engages in policy work to ensure that the Medicare program remains intact for members of future generations.
- National Council on Aging Benefits Checkup: With thousands of benefits programs available in the United States, it can be difficult to determine your eligibility. If you need help with health care, medications, housing, utilities, employment, tax relief, or other services, use the Aging Benefits Checkup to determine what assistance programs are available in your area.
- Medicare Resource Center: AARP’s website is home to the Medicare Resource Center, which provides information about Medicare eligibility and enrollment. The MRC publishes informative articles, fact sheets, and other resources on qualifying for Medicare, covering your out-of-pocket health care costs, and distinguishing between the different types of Medicare coverage.
- Social Security Administration: The Social Security Administration is a federal agency tasked with administering the Supplemental Security Income and Social Security Disability Insurance programs. If you receive SSDI benefits, you may also qualify for Medicare coverage. Employees at the SSA can help you determine your eligibility for benefits and navigate the enrollment process.
- Centers for Medicare & Medicaid Services: The CMS oversees the Medicare program and manages a variety of initiatives designed to reduce fraud and waste within the American health care system. If you suspect that one of your health care providers is overbilling Medicare or charging Medicare for services that were never rendered, contact the CMS to learn how to file a complaint.
- Medicare Interactive: Medicare Interactive is a reference tool designed to help older adults and individuals with a disability explore their health care options. The organization offers a wide range of resources for Medicare-eligible individuals, their family members, and professional caregivers, ensuring that all stakeholders can make informed decisions about medical care.
- National Association of Area Agencies on Aging: If you’re at least 60 years old and have a disability that makes you eligible for Medicare, your local Area Agency on Aging can provide information on enrolling in Medicare and finding other resources to help you manage your disability. You can use the National Association of Area Agencies on Aging website to find resources in your area.
FAQs About Medicare for People With Disabilities
The Medicare guidelines can be confusing, especially if you’re under the age of 65 and need to know if you qualify for coverage because you have ALS, ESRD, or another disability. Below you’ll find answers to some of the most frequently asked questions about Medicare for a person with a disability.
Who qualifies for Medicare with a disability?
You may qualify for Medicare if you’re under the age of 65 and have ALS, ESRD, or another disability that makes you eligible for disability benefits from the Social Security Administration or Railroad Retirement Board. The SSA defines a disability as a medical condition that’s expected to last for 12 months or more and renders you unable to perform your current duties or adjust to new duties at a different job. If you meet the eligibility requirements for SSDI, you may be automatically enrolled in Medicare Part A and Part B. Otherwise, you’ll need to initiate the enrollment process.
Is Medicare free if you’re disabled?
In most cases, Medicare isn’t free even if you qualify due to a disability. Medicare Part A, which covers inpatient care, is usually free, but you’ll need to pay a premium for Part B coverage. In addition to your part B premium, you may have to pay deductibles, copays, coinsurance, and other out-of-pocket costs. Because Original Medicare doesn’t cover most prescription drugs, you may also have to pay for a supplemental drug plan to ensure you can afford your medications each month. If you meet certain financial requirements, you may be able to get help covering these out-of-pocket costs.
Do you automatically get Medicare with a disability?
In some cases, you’re automatically enrolled in Medicare if you have a disability. This usually occurs when you’ve been receiving disability benefits from the Social Security Administration or the Railroad Retirement Board. If you have ALS and qualify for SSDI or RRB disability benefits, you’ll be enrolled in Medicare as soon as you’ve received one disability payment. Otherwise, you’ll be enrolled once you’ve been receiving SSDI or RRB disability benefits for 24 months. If you’re not automatically enrolled in Medicare due to your disability status, you should contact your local Social Security office or Railroad Retirement Board field office.
If you’re on Medicare for disability, what happens when you turn 65?
When you turn 65, you’ll no longer qualify for Medicare based on your disability. Instead, you’ll qualify based on your age. You’ll be able to continue your Original Medicare coverage or sign up for a Medicare Advantage Plan, just as you would if you’d never had Medicare coverage before. If you decided to delay your Part B enrollment when you were under the age of 65, you’ll be automatically enrolled in Part B and will need to decide if you want to keep Original Medicare or switch to Medicare Advantage. You’ll also have the opportunity to enroll in a Medicare Part D plan.
What happens if you get Medicare for a disability and then return to work?
The Social Security Administration offers incentives to allow people receiving SSDI benefits to explore their work options. During a nine-month trial period, you’ll continue collecting your SSDI benefits no matter how much you earn. Once you complete this trial period, your Medicare coverage will continue for at least 93 months, even if you earn too much to continue receiving your SSDI benefits.
If you receive RRB disability benefits, however, the requirements are different. The RRB may determine that you’ve participated in substantial gainful activity if you earn more than $1,020 per month after deducting your work expenses. If this occurs, your Medicare coverage will be terminated.
Learn More From Our Sources
- Medicare Interactive | How to Enroll in Medicare if You Have ALS | Last accessed August 2021
- Medicare | I Have End-Stage Renal Disease (ESRD) | Last accessed August 2021
- Social Security | How You Qualify | Last accessed August 2021
- U.S. Railroad Retirement Board | Medicare for Railroad Workers and Their Families | Last accessed August 2021
- Social Security Administration | Working While Disabled: How We Can Help | Last accessed August 2021
- U.S. Railroad Retirement Board | How Work Affects Your Disability Annuity | Last accessed August 2021
- Medicare Interactive | The 30-Month Coordination Period for People with ESRD | Last accessed August 2021
- Medicare | Joining a Health or Drug Plan | Last accessed August 2021
- HHS.gov | What is Medicare Part C? | Last accessed August 2021
- Medicare | Drug Coverage (Part D) | Last accessed August 2021
- Medicare | Medicare Plan Finder | Last accessed August 2021
- Medicare | Medicare Costs at a Glance | Last accessed August 2021
- Medicare | Part B Costs | Last accessed August 2021
- Medicare | Medicare Savings Programs | Last accessed August 2021
- Social Security | Extra Help with Medicare Prescription Drug Plan Costs | Last accessed August 2021